Medical imaging exchange network

ABSTRACT

A surgical imaging system includes a CT scanner and an image exchange system. A computer interfaces with an image exchange server over the Internet or over another wide area network. The image exchange server provides an offsite backup of images, provides a complete project management for medical procedures involving the images, and provides software available for trial and purchase for use on the surgical imaging system or other computers.

This application claims priority to United States ProvisionalApplication No. 60/797,565 filed May 4, 2006.

BACKGROUND OF THE INVENTION

The present invention relates generally to a network for managingmedical images and more particularly to a system and method for remotelystoring, accessing, processing and distributing medical images.

Medical imaging has widely evolved in the recent years, offeringsophisticated tests such as Computer Tomography (CT), Magnetic ResonanceImaging (MRI), ultrasounds, or the like. Manufacturers such as XoranTechnologies, Inc. produce a wide variety of such medical imagingdevices including compact CT scanners ideally suited for in-office oron-site imaging of numerous areas of the human body, including but notlimited to the temporal bones, the skull base, sinuses, and jaw/teeth.

Typically, users of compact imaging equipment of this type perform a CTscan and study, view and store the resulting image at the location wherethe CT scan was performed. The CT image may also need to be viewed byother doctors or specialists for a second opinion or by otherspecialists such as radiologists, dental implant manufactures and drillimplant manufacturers. The current procedure for providing thesenecessary parties with the patient's CT image typically involves copyingthe image to a compact disk or other similar storage medium and shippingthe image to the appropriate party.

Disadvantageously, this process may be time consuming and expensive. Forexample, it may take days for a doctor or specialist to receive thescanned image, review and analyze the image, and forward the image tothe next doctor or physician required to review the CT image. Also,“emailing” CT images is currently not feasible due to the extremelylarge size of the image files. This further makes the current process ofdistributing the scanned images impractical.

Accordingly, it is desirable to provide a system of storing, accessingand distributing medical images for users of medical imaging equipmentthat is simple and cost-effective to operate and that provides forremote viewing of medical images in a secured and controllable manner.

SUMMARY OF THE INVENTION

A surgical imaging system includes a CT scanner and an image exchangesystem. A computer interfaces with an image exchange server over theInternet or over another wide area network. Other users and computerscan access the image exchange server. The image exchange server providesan offsite backup of images, provides a complete project management formedical procedures involving the images and provides software availablefor trial and purchase for use on the surgical imaging system or othercomputers.

Copies of CT images stored on the computer are periodically andautomatically copied by software on the computer to the image exchangeserver and associated with a physician's account. The CT images on theimage exchange server are accessible only by the physician's account andthose accounts authorized by the physician. The physician handling thepatient grants the authority to remotely view selected CT images throughthe image exchange server to the patient, other physicians, orspecialists.

The image exchange server issues a notification to the outsidecontractors that access to the selected CT image(s) has been granted andspecific work is requested of them. The outside contractor may eitheraccept or reject the request, and the physician is notified of theacceptance or rejection.

Upon acceptance of the request to perform services, the image exchangeserver grants the outside contractor access to the CT images of thepatient. Based on the CT images, the outside contractors may then addcomments or markings to the CT images, design or locate implants withinthe CT images, or perform any other required services on or with the CTimages. If the outside contractor rejects the request, the imageexchange server notifies the handling physician, and another outsidecontractor is chosen to perform the required services.

The image exchange server monitors the progress of the outsidecontractors as the requested services are performed. The image exchangeserver notifies the handling physician of the progress of the outsidecontractor. The handling physician reviews the services performed by theoutside contractors and makes any necessary preparations for performanceof the required medical procedure.

The image exchange server can also coordinate payments and providesoftware that can be downloaded to other computers.

BRIEF DESCRIPTION OF THE DRAWINGS

The various features and advantages of the present invention will becomeapparent to those skilled in the art from the following detaileddescription of the currently preferred embodiment. The drawings thataccompany the detailed description can be briefly described as follows:

FIG. 1 schematically illustrates a first embodiment CT scanner;

FIG. 2 illustrates the CT scanner of FIG. 1 with a part of a patientreceived in the CT scanner;

FIG. 3 illustrates a second embodiment of the CT scanner;

FIG. 4 illustrates a perspective view of a CT scanning system includingthe CT scanner, a computer and an image exchange system;

FIG. 5 is a block diagram illustrating a method of storing, accessingand distributing CT images;

FIG. 6 illustrates a screen capture of a login page used to access animage exchange network;

FIG. 7 illustrates a screen capture of a patient search page forsearching for a patient on the image exchange network;

FIG. 8 illustrates a screen capture of a page that displays records of apatient; and

FIG. 9 illustrates a screen capture of a page used to provide outsidecontractor authorization.

DETAILED DESCRIPTION OF PREFERRED EMBODIMENTS

FIG. 1 illustrates a CT scanner 10 of a CT scanner system 8 (shown inFIG. 4) including a gantry 12 that supports and houses components of theCT scanner 10. Suitable CT scanners 10 are known. In one example, thegantry 12 includes a cross-bar section 14, and a first arm 16 and asecond arm 18 each extend substantially perpendicularly from opposingends of the cross-bar section 14 to form the c-shaped gantry 12. Thefirst arm 16 houses an x-ray source 20 that generate x-rays 28. In oneexample, the x-ray source 20 is a cone-beam x-ray source. The second arm18 houses a complementary flat-panel detector 22 spaced apart from thex-ray source 20. The x-rays 28 are directed toward the detector 22 whichincludes a converter (not shown) that converts the x-rays 28 from thex-ray source 20 to visible light and an array of photodetectors behindthe converter to create an image. As the gantry 12 rotates about thepatient P, the detector 22 takes a plurality of x-ray images at aplurality of rotational positions. Various configurations and types ofx-ray sources 20 and detectors 22 can be utilized, and the invention islargely independent of the specific technology used for the CT scanner10.

FIG. 2 illustrates the CT scanner 10 with a part of the patient Preceived in a space 48 between the first arm 16 and the second arm 18. Amotor 50 rotates the gantry 12 about an axis of rotation X to obtain aplurality of x-ray images of the patient P at the plurality ofrotational positions. The axis of rotation X is positioned between thex-ray source 20 and the detector 22. The gantry 12 can be rotatedapproximately slightly more than 360 degrees about the axis of rotationX. In one example, as shown in FIGS. 1 and 2, the axis of rotation X issubstantially horizontal. In this example, the patient P is typicallylying down on a table 70. Alternatively, as shown in FIG. 3, the axis ofrotation X is substantially vertical. Typically, in this example, thepatient P is sitting upright.

As shown schematically in FIG. 4, a CT scanner system 8 further includesa computer 30 having a microprocessor or CPU 32, a storage 34 (memory,hard drive, optical, and/or magnetic, etc. or other local storage), adisplay 36, a mouse 38, a keyboard 40 and other hardware and softwarefor performing the functions described herein. The computer 30 powersand controls the x-ray source 20 and the motor 50. The plurality ofx-ray images taken by the detector 22 are sent to the computer 30 andstored. The computer 30 generates a three-dimensional CT image from theplurality of x-ray images utilizing any known techniques and algorithms.The three-dimensional CT image is stored on the storage 34 of thecomputer 30 and can be displayed on the display 36 for viewing. Anoperator controls the CT scanning system 8 using the computer 30

The CT scanning system 8 includes an image exchange system 58. Thecomputer 30 (or a separate computer) interfaces with an image exchangeserver 52 over the Internet or over another wide area network 46. Theimage exchange server 52 is accessible to other authorizedusers'computers 56 a and 56 b, including other CT scanning systems andother users, via the wide area network 46.

The image exchange server 52 generally provides three features: 1) anoffsite backup of images; 2) complete project management for medicalprocedures involving the images; and 3) software available for trial andpurchase for use on the CT scanning system 8 or other computers.Although the image exchange system 58 of the present invention isillustrated for use with a CT scanning system 8, it should be understoodthat other medical imaging devices, including but not limited to MRI andultrasound devices, may employ the image exchange system 58 of thepresent invention.

The CT scanner 10 takes a plurality of x-ray images that are used tocreate the CT images. In operation, copies of the CT images stored onthe computer 30 are periodically and automatically copied by software onthe computer 30 to the image exchange server 52 and associated with aphysician's account. The CT images on the image exchange server 52 areaccessible only by the physician's account and those accounts authorizedby the physician. This provides an automatic offsite backup of the CTimages, while relieving the physicians of the time, effort and costnecessary to make periodic backups for offsite storage.

Once a CT image of the patient P is uploaded onto the image exchangeserver 52, the physician handling the patient P may, using the computer30 or another computer, grant the authority to remotely view selected CTimages through the image exchange server 52 to the patient, otherphysicians, or specialists. The physician does this by granting accessto the selected CT images to the associated accounts of the otherpeople. The image exchange server 52 includes a database of numerousaccounts for all of the people who require access. The physician canaccess the database to find the people to whom access should be granted,or, especially in the case of a new patient, create a new account (userID and password) to which access can be granted.

The physician also manages the project involving the selected CT imageusing the image exchange server 52, including 1) choosing outsidecontractors (other physicians, specialists, implant manufacturers, etc);2) requesting tasks to be performed by the outside contractors relatingto specific CT images; 3) monitoring responses (acceptance or rejection)from outside contractors to task requests; 4) monitoring the progress ofthe outside contractors on the requested tasks. The image exchangeserver 52 also coordinates among the outside contractors as necessary,for example, by notifying one contractor when a prerequisite work hasbeen completed by another contractor. The image exchange server 52 mayalso optionally coordinate billing and payment among the physician,patient, insurance company and outside contractors for the servicesperformed in connection with the CT images. One example project isdescribed below.

Referring to FIG. 5, a method 100 for storing, accessing anddistributing CT images through the image exchange server 52 isillustrated. The following method 100 is illustrated in terms of adental implant procedure. Although the example is illustrated in termsof a dental implant procedure, it should be understood that the methodmay be utilized in other situations including, but not limited to,procedures involving the temporal bones, skull base, or sinuses.

The method 100 begins at step 102 where a physician conducts an initialconsultation with a patient P, and the physician determines that thesurgical installation of a unique dental implant is necessary. Next, atstep 104, the appropriate CT scans of the patient P are obtained, and acopy of the CT image obtained from the CT scan is uploaded onto theimage exchange server 52 at step 106. At step 108, the physicianhandling the patient P (i.e., the handling physician) requestsadditional services to be performed by outside contractors (i.e., otherdoctors, surgeons, radiologists, specialists, etc.) based upon the needsof the patient as determined from the CT images.

The handling physician may either request specific outside contractorsto perform specific tasks (from a list of available outside contractorswith accounts on image exchange server 52) or request referrals from theimage exchange server 52. The handling physician may grant authorizationto any person or organization with an account on image exchange server52 to access selected CT images (see FIG. 9).

It is expected that physicians would usually be repeatedly initiatingthe same project for many different patients. In that case, thephysician would store his preferences for outside contractors for eachof the tasks of the project so that the physician could simply choosethat project for a selected CT image, and the preferred outsidecontractors would automatically be assigned.

When referrals for an outside contractor in a selected category arerequested by the handling physician, the image exchange server 52displays a list of qualified outside contractors on the display 36 ofthe computer 30 to the handling physician. The handling physician and/orthe patient P may then choose the outside contractor that best fit theirneeds. That is, the image exchange server 52 includes a completereferral network as a component of its project management capabilities,thereby further simplifying the procedure for both physicians andpatients.

In step 110, the image exchange server 52 issues a notification to theoutside contractors that access to the selected CT image(s) has beengranted to them and that specific work on the project is requested ofthem. The notification may be done through the outsidecontractors'accounts on the image exchange server 52 and/or via outsideemail. The outside contractor access the image exchange server 52 usingcomputers 56 a and 56 b over the wide area network 46. The outsidecontractor may either accept or reject the request, and the physician isnotified of the acceptance or rejection.

Upon acceptance of the request to perform services, the image exchangeserver 52 grants the outside contractor access to the CT images of thepatient P at step 112. The outside contractors may then add comments tothe CT images, mark up the CT images, design implants based upon the CTimages, locate implants within the CT images or perform any otherrequired services on or with the CT images. The handling physician canselect several outside contractors and select the specific images towhich each outside contractor has access. For example, the handlingphysician restricts access such that each outside contractor only hasaccess to specific images.

In the event the outside contractor rejects the handling physician'srequest to perform services, the image exchange server 52 issues anotification indicating such rejection to the handling physician at step114. The method 100 then returns to step 108 where a second outsidecontractor is chosen to perform the required services. Alternatively,the image exchange server 52 may automatically contact alternativeoutside contractors approved by the physician upon the rejection by thefirst outside contractor.

At step 116, the image exchange server 52 tracks the progress of theoutside contractors as the requested services are performed. The imageexchange server 52 notifies the handling physician of the progress ofthe outside contractor at step 118. For example, the image exchangeserver 52 may send a series of email progress reports to the handlingphysician. Alternatively, a listing of all of the physician's openprojects may be displayed in a single list along with a summary of theprogress of each project. Additionally, since some tasks are typicallyperformed sequentially by several outside contractors, the imageexchange server 52 may notify one outside contractor of another outsidecontractor's progress to date or notify the outside contractor when thework of a previous outside contractor is completed. Because the outsidecontractors may be working on many projects for many differentphysicians, a listing of their active projects may be displayed to them,along with a status indicator, priority indicator, deadline, etc.

For example, in the dental implant field, the CT images may need to bereviewed by a second physician, a radiologist, a drill templatemanufacturer and an implant manufacturer. First, the patient may requesta second physician to review the CT image for a second opinion. Also, aradiologist may be required to review the CT image to screen forpotential issues, such as tumors. These tasks can be assigned andperformed simultaneously. Once these parties have completed their reviewof the CT images and made all necessary annotations (or simultaneously),the image exchange server 52 sends a notification to the implantmanufacturer that the CT image is available to access. The implantmanufacturer accesses the CT image and designs an appropriately sizeddental implant for a patient P. The implant design is added to the CTimage (as a separate layer, or in an otherwise non-destructive manner).Once the implant manufacture has completed the implant design, anotification is sent to the handling physician requesting approvaland/or comments on the implant design. After approval, or automatically,notification is given to the drill template manufacturer, who designs atemplate based upon the CT image and based upon the implant design,which has been added to the CT image. By tracking all markups and theprogress of every party involved in completion of the medical procedure,the image exchange server 52 acts as a project manager and effectivelystreamlines the entire surgical procedure.

At step 120, the handling physician reviews the services performed byall outside contractors and makes any necessary preparations forperformance of the required medical procedure. The implant and templateare shipped to the physician. The method 100 ends at step 122 where themedical procedure is completed.

One additional capability of the image exchange server 52 is the abilityto coordinate payments. For example, as stated above, the dental implantfield often requires the services of a second physician, a radiologist,a drill template manufacturer, and an implant manufacturer. All of theseoutside contractors require a fee for the services they provide. Theimage exchange server 52 may be programmed with the necessary softwareto control the money transactions involved in paying for these outsidecontractor's services. One of ordinary skill in the art with the benefitof the teachings herein will be able to implement the appropriateinstructions to facilitate the execution of money transactions.

In one example, the patient P logs onto the image exchange server 52 andprovides credit card information. The image exchange server 52 thenautomatically deducts funds from the credit card of the patient P andpays the appropriate outside contractor via an electronic money transferonce authorization is given that the services were adequately completed.In another example, insurance information is programmed into the imageexchange server 52 such that an automatic bill is produced and sent bythe image exchange server 52 to the relevant insurance agency once theoutside contractor's services are completed.

In addition to storage capabilities, the image exchange server 52 alsoincludes numerous types of software that can be downloaded to thecomputer 30 for trial or purchase, including implant planning software,commenting software or any other CT scan related software. Softwarepurchased from the image exchange server 52 is billed to the accountassociated with the computer 30, 56 a and 56 b that downloaded it.

Additionally, the network can prioritize how the images are transferredfrom the image exchange server 52 to the secondary contractor'scomputers 56 a and 56 b. Numerous images for each patient can be storedon the image exchange server 52, and therefore it can be time consumingto transfer the images to the secondary user's computers 56 a and 56 b.For example, when the secondary contractor views the images, he canselect an image of increased priority. The image exchange server 52 willfirst transfer this image to the secondary contractor's computer 56 aand 56 b, allowing the outside contractor to begin reviewing andannotating the image. As the outside contractor continues to review theimage, the remaining images can be transferred to the outsidecontractor's computer 56 a and 56 b. This speeds up the transfer of thehigher priority images to the outside contractor's computer 56 a and 56b so he can begin work immediately.

FIGS. 6 to 9 illustrate screen captures shown on the display 36 of thecomputer 30 (or any computer) when using the software and accessing theimaging exchange network. For example, as shown in FIG. 6, the userfirst sees a login page 200. On the login page 200, the user inputs anemail address in a field 202 and a password in a field 204 to access theimaging exchange network.

As shown in FIG. 7, the user can then access a patient search page 206where the user can input information to search for a patient's Precords. A patient's P records can be accessed by inputting a first namein a field 208, a last name in a field 210, a study date in a field 212or a study title in a field 214. The user can also select all studiesacquired in a given time period using a drop-down menu 216.

As shown in FIG. 8, once the records of the patient P are identified,the user is then taken to an image page 218 that displays the images 220of the patient P. The group of physicians, outside contractors andauthorized users that are authorized to access the images 220 is shownin a field 222. Notes about the images 220 can be made by the outsidecontractor in a section 224. The images 220 can also be marked-up,reviewed and noted by the outside contractor using a tools section 226,allowing the outside contractor to perform the requested tasks.

For example, the tools section 226 can include several icons that theoutside contractor can use to perform the requested tasks. Example iconsinclude a viewing tools icon 300 to reset the screen, a zoom/unzoom/dragicon 302 to enlarge, reduce or move a selected image, a contrast icon304 to adjust the contrast of the selected image and a measurement icon306 to measure a selected portion of the selected image. The toolssection 226 can also include an icon 308 that is clicked to determine amean/standard deviation density in an area of interest (circled area), alabel icon 310 to label the selected image, a label with arrow icon 312to label the selected image, and an icon 314 to determine themean/standard deviation density in an area of interest (squared area).The tools section 226 can also include an icon 316 for panoramictracing, an icon 318 for temporomandibular tracking, and an icon 320 forsingle plane tracing. The tools section 226 can further include a labellist icon 322 that is clicked to provide a list of labels that can beused by the user to annotate the selected image, a data compression icon324 that can be clicked to compress the data and a column display icon326 to show the data in a column.

The specific tools/icons displayed in the tools section 226 on the imagepage 218 can be customized based on the user. For example, if a user inthe dental field is using the software, the software is programmed suchthat the tools needed specifically for dental images are active. Anynon-essential tools can be darkened and inactivated or removed.

FIG. 8 also shows a viewing section 400 of the image page 218. Theviewing section 400 includes icons that can be clicked to select adesired view of the image. The viewing section 400 includes a quadranticon 102 to view several views of the image (default image), a frontalicon 404 to view a front view of the image, a sagittal icon 406 to viewa side view of the image, an axial icon 408 to view a top view of theimage, a CT data parameter icon 410 to view the parameters of the CTdata, and a selected sections icon 412. The selected sections icon 412displays sections pre- programmed by a user.

The quadrant 414 can display a three-dimensional rendering of the image.Tools can be provided to change the view of the three-dimensional imageand perform any requested tasks on the three-dimensional image.

Although numerous icons and tasks are illustrated and described, it isto be understood that any combination of the icons/tasks can be used orother icons can be added or deleted based on the desired task.

To change the list of people with access to the patient's P records, thephysician clicks the edit button 228, taking the physician to theoutside contractor editing page 230 shown in FIG. 9. The physician canadd outside contractors to the authorization list by inputting orselecting the names of the outside contractors in a field 232. An arrow234 can be clicked to add the outside contractors to the “preferredlist” shown in a field 236. An individual on the “preferred list” can beremoved by highlighting the outside contractor's name and clicking theremove button 238.

The foregoing description shall be interpreted as illustrative and notin any limiting sense. A worker of ordinary skill in the art wouldrecognize that certain modifications would come within the scope of thisinvention. For that reason, the following claim should be studied todetermine the true scope and content of this invention.

1. A method for managing an image of a patient, the method comprisingthe steps of: generating an image of a patient; storing the image on aremote centralized server; authorizing at least one user to remotelyaccess the image; and remotely accessing the image.
 2. The method asrecited in claim 1 further including the step of annotating the image.3. The method as recited in claim 2 further including the step ofselecting the at least one user, wherein the at least one user performsthe steps of remotely accessing the image and annotating the image. 4.The method as recited in claim 2 wherein the at least one user comprisesa first outside contractor and a second outside contractor, the methodfurther including the step of notifying the second outside contractorwhen the first outside contractor completes the step of annotating theimage.
 5. The method as recited in claim 2 further including the step ofreviewing annotations provided by the at least one user.
 6. The methodas recited in claim 5 further including the step of determining aprocedure to perform on the patient based on the step of reviewing theannotations.
 7. The method as recited in claim 1 wherein the step ofgenerating the image of the patient includes taking a plurality of x-rayimages to create a CT image.
 8. The method as recited in claim 1 furtherincluding the steps of storing the image on a computer and uploading theimage from the computer to the remote centralized server.
 9. The methodas recited in claim 1 further including the steps of storing the imageon a first computer and uploading the image from the first computer tothe remote centralized server before the step of storing the image onthe remote centralized server, wherein the step of remotely accessingthe image is performed on a second computer by the at least one user.10. The method as recited in claim 9 wherein an originating physicianuses the first computer and the at least one user is an outsidecontractor that uses the second computer.
 11. The method as recited inclaim 1 further including the step of requesting the at least one userto review the image.
 12. The method as recited in claim 11 furtherincluding the step of accepting a request to review the image.
 13. Themethod as recited in claim 11 further including the steps of rejecting arequest to review the image and then choosing another at least one userto review the image.
 14. The method as recited in claim 1 furtherincluding the step of monitoring work performed by the at least oneuser.
 15. The method as recited in claim 1 further including the step ofcoordinating payments to the at least one user.
 16. The method asrecited in claim 1 further including the step of downloading softwarefrom the remote centralized server to a computer.
 17. The method asrecited in claim 1 wherein the image comprises a primary image and aplurality of secondary images, the method further including the steps ofselecting the primary image, transferring the primary image to acomputer of the at least one user, and reviewing the primary image whilethe plurality of secondary images transfer to the computer of the atleast one user.
 18. The method as recited in claim 1 wherein the imagecomprises a first image and a second image and the at least one usercomprises a first user and a second user, wherein the step ofauthorizing the at least one user includes authorizing the first user toremotely access at least the first image and authorizing the second userto remotely access at least the second image.
 19. A method for managinga CT image of a patient, the method comprising the steps of: taking aplurality of x-ray images to create a CT image of a patient; uploadingthe CT image to a remote centralized server; storing the CT image on theremote centralized server; authorizing at least one outside contractorto remotely access the CT image; remotely accessing the CT image;annotating the CT image; and monitoring work performed by the at leastone outside contractor.
 20. The method as recited in claim 19 furtherincluding the step of selecting the at least one outside contractor,wherein the at least one outside contractor performs the steps ofremotely accessing the CT image and annotating the CT image.
 21. Themethod as recited in claim 19 further including the step of requestingthe at least one outside contractor to review the image.
 22. The methodas recited in claim 21 further including the step of accepting a requestto review the image.
 23. The method as recited in claim 21 furtherincluding the steps of rejecting a request to review the image and thenchoosing another at least one outside contractor to review the image.24. The method as recited in claim 19 further including the step ofreviewing annotations provided by the at least one outside contractor.25. The method as recited in claim 19 further including the steps ofstoring the image on a first computer, and the step of uploading theimage to the remote centralized server includes uploading the image fromthe first computer to the remote centralized server, wherein the step ofremotely accessing the image is performed on a second computer by the atleast one outside contractor.
 26. The method as recited in claim 25wherein an originating physician uses the first computer and the atleast outside contractor uses the second computer.
 27. The method asrecited in claim 19 further including the step of coordinating paymentsto the at least one outside contractor.
 28. The method as recited inclaim 19 further including the step of downloading software from theremote centralized server to a computer.
 29. A surgical imaging systemcomprising: an image device to take an image of a patient; a firstcomputer to store the image; a remote centralized server, wherein thefirst computer interfaces with the remote centralized server and uploadsthe image to the remote centralized server; and a second computer,wherein the second computer interfaces with the remote centralizedserver to remotely access the image, a first user authorizes a seconduser to remotely access the image, and the second user annotates theimage on the second computer.
 30. The surgical imaging system as recitedin claim 29 wherein the first computer and the second computer interfacewith the remote centralized server over a wide area network.
 31. Thesurgical imaging system as recited in claim 29 wherein the image deviceis a CT scanner and the image is a CT image.
 32. The surgical imagingsystem as recited in claim 29 wherein the first user uses the firstcomputer to monitor work performed by the second user on the secondcomputer.
 33. The surgical imaging system as recited in claim 29 whereinthe first user uses the first computer to review annotations provided bythe second user on the second computer.